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Developing and Implementing an HIV/AIDS Educational Curriculum for Older Adults

Correspondence: Address correspondence to Joanne Altschuler, PhD, LCSW, School of Social Work, California State University, 5151 State University Drive, Simpson Tower F808, Los Angeles, CA 90032. E-mail: jaltsch{at}calstatela.edu

	Abstract

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Purpose: Recent data (2002) from the Centers for Disease Control and Prevention indicate that almost 11% of all cases of AIDS were diagnosed in people 50 and older. Despite the steady rise and future projections of increase, there is still a paucity of education and prevention programs targeting this population. This article reports on the development and piloting of an HIV/AIDS education prevention program. It describes an educational curriculum that provides older adults with accurate information about the relevance of HIV/AIDS to their lives. Design and Methods: A purposive sample (n = 249) of ethnically and economically diverse adults 50 years and older was selected from 14 organizations in rural and urban settings in California. They were surveyed to determine their interest in participating in HIV/AIDS education prevention programs. Results: A majority of participants reported interest in an HIV/AIDS prevention program for older people, with female respondents more likely to attend than male respondents. Participants who were moderately or very religious were also more likely to attend. Participants expressed preference for prevention education through presentations at centers serving older adults, and from physicians and other health care providers. On the basis of these findings, a specialized curriculum targeting older adults was developed, presented, and disseminated. Implications: People 50 years and older are sexually active, lack accurate information about HIV/AIDS, and are in need of HIV/AIDS education.

Key Words: Older adults • HIV/AIDS education • HIV/AIDS prevention

Riley, Ory, and Zablotsky (1989) stated that one of the reasons for this underreporting is because "the best available statistics for the United States derive not from cases of HIV infection but from cases [of persons] diagnosed as having AIDS, as these are reported to the Centers for Disease Control" (p. 9). Potential underreporting of HIV infection among older adults may also be due to the fact that HIV infection in the United States is typically perceived to be a young person's virus. For example, older people themselves, as well as doctors and other health care providers, are less likely to think of older adults as being at risk (El-Sadr & Gettler, 1995; Mack & Bland, 1997). This common perception results in the tendency of older adults to be diagnosed at a late stage of infection, often when they seek treatment for an HIV-related illness (Solomon, 1996).

Another reason why cases of HIV or AIDS may be underreported among older people is because HIV infection resembles other diseases associated with aging. For example, AIDS-related dementia might be misdiagnosed as Alzheimer's disease; early HIV symptoms such as fatigue and weight loss might be erroneously considered a normal part of aging. Similarly, HIV symptoms of confusion, memory loss, and fatigue might be falsely attributed to an older person's alcoholism (Aupperle, 1996).

Despite misconceptions that HIV/AIDS only affects young people, it is important to emphasize that older adults have the same risk factors for HIV infection and transmission as younger people. The risk factors of engaging in unprotected sexual contact, sharing needles, and exchanging bodily fluids apply to all ages. For example, older injecting-drug users account for 16% of the AIDS cases of persons over the age of 50 (Center for AIDS Prevention Studies, 1998). There are, however, several ways in which risk behaviors for contracting HIV differ between older adults and younger people. One way is that people over 50 tend to use condoms less frequently than younger adults (Stall & Catania, 1994). A second way pertains to potential cultural taboos that preclude open discussion of issues pertaining to sexuality among older adults (Anderson, 1998). A third way concerns potential generational and cohort differences. Older people may be less comfortable discussing their sexual behaviors or drug use with others. For example, Latino cultural values around machismo, the role of women, and the significance of inclusion and family origin may create undue strain on older sexually active heterosexual and homosexual Latina females (Morales, 1989). In addition, normal physiological changes can put older women at higher risk for HIV infection during sexual intercourse (Center for Women Policy Studies, 1994).

Stereotypes regarding older adults, sexuality, and high-risk behaviors reinforce societal perceptions that older adults are not at risk of contracting HIV or AIDS. Engle (1998) offered this concise summary of societal stereotypes: "old people are no longer interested in sex; if they are interested, no one's interested in them; if they do have sex, it's within a monogamous, heterosexual relationship; they don't do drugs; and if they ever did, it's so long ago it doesn't matter" (p. 1). Although men having sex with men remains the largest at-risk group among older adults, other groups have increased at faster rates and now account for higher percentages. For example, over the past decade there has been a significant increase in the number of older adults infected through heterosexual contact (Puleo, 1996), injection drug use (Gordon & Thompson, 1995), and undetermined or unknown exposure (Ory & Mack, 1998).

In spite of increasing incidence (CDC, 2001) and factors that put older adults at risk for HIV and AIDS, older adults have received little attention compared with other age groups at risk of contracting HIV/AIDS. The need for prevention programs and education campaigns is well documented. For example, Linsk (2000) pointed out that prevention messages primarily target young adults, children, and teenagers, arguing that "the lack of targeted HIV prevention information reinforces the myth that HIV does not apply to older adults" (p. 432).

Although older adults have not traditionally been targeted to receive even the most basic HIV/AIDS education and prevention information, several model curricula, self-help networks, and educational videotapes have been developed to educate older adults about HIV/AIDS (see the appendix for a listing of model curricula, self-help networks, and educational videotapes).

Because of the statistical trends documenting older adults' risk for HIV/AIDS and the need for prevention efforts targeting older adults, we conducted a research project (1997–1999) that surveyed HIV/AIDS knowledge and prevention; perception of relevance; sexual attitudes; risk behaviors; and participation in prevention education programs among people 50 and over. We developed and implemented an HIV/AIDS educational curriculum for older adults (Altschuler, Katz, & Tynan, 2000). However, because of the purpose and scope of this article, we report and discuss only the measures concerning the research participants' preferences regarding interest and participation in education and prevention programs.

	Methods

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Sample and Design
A purposive sample (n = 249) was selected from 14 organizations serving adults 50 years of age and older in California: 7 from a rural central region (n = 123) and 7 from an urban southern region (n = 126). We approached organizations that are publicly recognized for excellence in serving economically and ethnically diverse adults aged 50 and older. Organizations included multipurpose senior centers, recreation centers for older adults, meal sites, a drug and alcohol intervention program, and a popular social club. All procedures were taken to protect human participants, and the study received full California State University Institutional Review Board approval before the project was implemented. The sole criterion for inclusion in the study was age. However, we were hoping for and achieved an ethnically and economically diverse sample by virtue of the organizations selected. Table 1 lists the demographic and background characteristics of the total sample.

Participants were asked 10 questions concerning interest in prevention and education (Table 2).

	Results

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Participants who self-reported as moderate or very religious were found to be more likely to attend an HIV/AIDS prevention education program compared with those who were not religious (² = 7.592, df = 2, p =.023). In addition, participants who self-identified as Hispanic were overrepresented in the group that is likely or very likely to attend (² = 47.633, df = 20, p =.000).

Responses to Question 5 indicate that older adults prefer learning more about HIV/AIDS through education programs and in-service trainings (37.3%), physicians (22.2%), and programs led by experts at senior centers (16.2%).

The Program Model
Findings presented in Table 2 guided the decision to disseminate HIV/AIDS information as an education training program in community settings serving older adults. The content was designed to include the overlap of recommendations from three specific sources: (a) experts in the area of HIV/AIDS and older adults (DeCarlo & Linsk, 1997; Meah, 1999; Ory, Zablotsky, & Crystal, 1998; Rae, 1997; Strombeck & Levy, 1998); (b) informal feedback from local Area Agency on Aging case managers, supervisory staff of the local Department of Aging, executive directors of two local multipurpose centers for senior citizens, and members of the local Asian Pacific Islander Task Force; and (c) the aforementioned model curricula. These sources concur that successful prevention programs targeting older adults incorporate cultural sensitivity and generational concerns, and they target such high-risk groups as gay men, minority women, and recently widowed women. There is also consensus that leaders need group skills, whether peer or otherwise, and that they be knowledgeable about the particular values and needs of the group they are addressing.

The curriculum was pilot tested with 20 older adults in each region (n = 40) from multipurpose senior centers that had not participated in the initial survey. We used verbal group feedback from participants during the session to refine the final curriculum. We also used verbal feedback from sources where the authors gave presentations on HIV/AIDS and older adults, including (a) professional audiences at state and national conferences; (b) ombudsman groups in Los Angeles County; (c) graduate and undergraduate students in the fields of gerontology, social work, and pharmacology; and (d) professionals working with older adults in the Greater Los Angeles Area.

The curriculum addresses basic information concerning HIV and AIDS and the impact on people 50 years old and older. The curriculum can be presented by itself or as part of a general health series for older adults. Presented by itself, it consists of four sections that take approximately 3 hr to present. Section 1, Introduction and Overview, takes approximately 25 min; Section 2, Identifying Myths and Stereotypes, takes approximately 70 min; Section 3, HIV/AIDS Facts, takes approximately 70 min; and Section 4, Resources, takes approximately 15 min. The curriculum and its purpose, goals, and objectives are respectively summarized Tables 3 and 4.

	Discussion

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Process variables have to be analyzed in order for us to understand what makes a program successful in helping older adults make use of education information and change their behaviors. For example, we observed that creating a welcoming environment (e.g., comfortable chairs, tables for written exercises, adequate lighting, and familiar foods) encouraged conversation and personal exchanges. So-called small talk occurred when people were eating and drinking together before the official program started. This appeared to help participants feel at ease during the formal program. These observations warrant further exploration and testing as factors that improve the effectiveness of an HIV/AIDS education program targeting older adults.

To what extent is a successful HIV/AIDS prevention or education curriculum related to the leader's ability to communicate in a nonjudgmental and effective manner with the broadest spectrum of older adults? A skillful leader understands the multiple psychosocial needs and cultural diversity of older adults. For example, the stigma attached to HIV/AIDS may result in older people's hesitating to speak directly about the topic with family, friends, or health care providers. In addition, older gay, lesbian, or bisexual adults often bring experiences and expectations that reflect many years "in the closet." We observed the importance of creating an atmosphere that does not assume only heterosexual identity among older participants. The degree to which these observations contribute to a successful learning experience for older adults warrants further exploration.

One obstacle to educating older adults about HIV/AIDS is the lack of perceived relevance to their lives. If offered as part of a health series, might exposure to the topic be sufficient to warrant change? The effectiveness of a stand-alone program versus the effectiveness of offering an education program as part of a health series warrants future investigation, as do the findings about less attendance as age increases, and higher religiosity associated with increased likelihood of attendance.

Finally, effective interventions specifically targeting health care providers are needed. When conducting assessments and evaluating symptoms, doctors and other medical practitioners need further education about older adults' risks for HIV/AIDS as well as increased awareness of cultural values and behaviors. Programs that are sensitive to differences in group composition and cohort desires (e.g., same sex vs. mixed; young-old vs. old-old groups) are also necessary to address the needs of increasing numbers of diverse older adults. The challenge is to design and determine which programs are effective in addressing the differences of the varied subpopulations among older adults.

	Appendix

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Model Curricula, Self-Help Networks, and Educational Videotapes

1. 1. SAGE (Senior Action in a Gay Environment) developed a 1-hr workshop that focuses on basic facts about symptomology, virology, immunology, transmission, prevention, and the roles of the older adult as caretaker.
   
2. 2. Strombeck's (1993) workbook and leader's guide, entitled AIDS and Aging: What People Over Fifty Need to Know: Strombeck's program is a study circle model based on reading and discussion, with everyone being an active participant.
   
3. 3. NAHOF (National Association of AIDS/HIV Over Fifty): NAHOF was founded at the National Conference on AIDS and Aging in October of 1995 in New York City. It provides education, advocacy, and a forum to exchange and share information, concerns, issues, and resources.
   
4. 4. SHIP (Senior HIV Intervention Project): SHIP is a publicly funded program that trains older peer educators to present educational and safer sex seminars at retirement communities. In addition, trained AIDS educators meet with health care professionals and aging services workers to help them understand the risk posed to seniors by HIV.
   
5. 5. National Minority AIDS Council (2001, September), "HIV/AIDS and Older Americans"; AARP's video kit (1985), "HIV+AIDS and Older Adults: It Can Happen to Me."
   
6. 6. HealthCare Education Associates (1995), "The Forgotten Tenth."
   

	Footnotes

 
This research was supported by a grant (Award No. K97-CSST-121) from the University of California Universitywide AIDS Research Program.

¹ School of Social Work, California State University, Los Angeles.

² Leonard Davis School of Gerontology, University of Southern California, Los Angeles.

³ Department of Social Work, California State University, Turlock.

Decision Editor: David E. Biegel, PhD

Received for publication November 26, 2002. Accepted for publication April 11, 2003.

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